Kti M Shadiq Aulia Rahman

NURSING CARE REPORT ON MR.
S WITH DYSPEPSIA
MEDICAL DIAGNOSIS IN TULIP IIIC WARD
BANJARMASIN ULIN GENERAL HOSPITAL
SCIENTIFIC PAPER
By:
MUHAMMAD SHADIQ AULIA RAHMAN
SRN : 12144011156 D3KI
BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE
INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM
BANJARMASIN, 2014/2015
NURSING CARE REPORT ON MR. S WITH DYSPEPSIA
MEDICAL DIAGNOSIS IN TULIP IIIC WARD AT
BANJARMASIN ULIN GENERAL HOSPITAL
Proposed to Fulfill One of the Requirements to Accomplish
International Class of Nursing Diploma Program
By :
MUHAMMAD SHADIQ AULIA RAHMAN
SRN : 1214 4011 156
BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE
INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM
ACADEMIC YEARS 2014/2015
i
ii
iii
PREFACE
,

.
Thanks to Allah SWT. The writer can finish this Nursing Care Report on Mr. S
with Dyspepsia Medical Diagnosis in Tulip IIIC Ward at Banjarmasin Ulin
General Hospital as a requirement for International Class of Nursing Diploma
Program accomplishment. The writer would like to give great gratitude to :
1. Thanks to Allah SWT.

2. Thanks to prophet Muhammad SAW.
3. Mr. M. Syafwani, S.Kp.,M.Kep.Sp.Jiwa, The Head of College.
4. Mr. Muhsinin, M.Kep.,Sp.Anak, The Coordinator of International Class.
5. Mrs. Dewi Setya Paramita, S.Kep., Ns, The first Advisor.
6. Mrs. Yulida Hermaniar, M.Pd. The second advisor.
7. Mrs. Dewi Setya Paramita, S.Kep., Ns, The First Examiner.
8. Mrs. Yulieda Hermaniar, M.Pd, The Second Examiner.
9. Mr, H. Iswantoro, S.Kep. MM, The Third Examiner.
10. Mrs. Laila, AMK. Clinical Instructor of Tulip IIICWard Banjarmasin Ulin
General Hospital.
11. All of the Lecturers and Staff of Banjarmasin Muhammadiyah Health
College.
12. My Beloved Father and Mother, who have given me power, spirit and
always pray and support me until right now, so I can finish my study.
13. All of Friends and Anyone who help me finish this final report.
iv
This report still has many mistakes and needs suggestions and comments from
all of stake holders.
Banjarmasin, July, 2015
The Writer
v
CONTENTS
Page number
TITLE PAGE .......................................................................................... i
ADVISORS APPROVAL ..................................................................... ii
ACKNOWLEDGEMENT ...................................................................... iii
PREFACE .............................................................................................. iv
CONTENTS ........................................................................................... vi
LIST OF TABLES ................................................................................... viii
LIST OF APPENDIXES .......................................................................... ix
CHAPTER 1 INTRODUCTION .............................................................. 1

1.1. Background ................................................................ 1
1.2. Problem Formulation .................................................. 3
1.3. Purpose ...................................................................... 3
1.4. Benefit of Writing ..................................................... 4
1.5. Writing Method and Technique of Collecting Data ..... 5
CHAPTER 2 THEORETICAL REVIEW ................................................ 6

2.1. Anatomy and Physiology ............................................ 6
2.2. Definition ................................................................... 9
2.3. Etiology ..................................................................... 10
2.4. Pathophysiology ......................................................... 11
2.5. Pathway ..................................................................... 14
2.6. Sign And Symptom ................................................... 15
2.7. Diagnostic Examination ............................................. 15
2.8. Treatment ................................................................... 16
2.9. Complication .............................................................. 18
2.10. Prognosis.................................................................... 18
2.11. Nursing Care Plan ..................................................... 19
2.12. Assessment................................................................. 19
2.13. Nursing Diagnosis and Interventions ......................... 24
CHAPTER 3 NURSING CARE .............................................................. 29

3.1. Clients Identity.......................................................... 29
3.2. Health History ............................................................ 29
3.3. Physical Examination ................................................. 30
3.4. Physical, Psychological, Social, Spiritual Needs ......... 34
3.5. Focus Data ................................................................. 37
3.6. Supporting Examination ............................................. 39
3.7. Pharmacology Therapy ............................................... 42
3.8. Data Analysis ............................................................. 42
3.9. Problem Priority ......................................................... 44
3.10. Intervention ................................................................ 45
vi
3.11. Implementation .......................................................... 48
3.12. Evaluation .................................................................. 52
3.13. Progress Note ............................................................. 53
CHAPTER 4 CLOSSING ........................................................................ 81

4.1 Conclusion ................................................................... 81
4.2 Suggestion ................................................................... 82
REFERENCE ......................................................................................... 84
APPENDIXES
CURICULUM VITAE
vii
LIST OF TABLES
Table Page number

st
3.1 Laboratory Result on june 1 2015......................................... 39
3.2 Laboratory Result on june 4th 2015 ....................................... 40
th
3.3 Laboratory Result on june 6 2015 ....................................... 41
3.4 Pharmacology Therapy .......................................................... 42
3.5 Data Analysis ........................................................................ 42
3.6 Intervention ........................................................................... 45
3.7 Implementation ...................................................................... 48
3.8 Evaluation ............................................................................. 52
3.9 Progress Note ....................................................................... 53
viii
LIST OF APPENDIXES
Appendixes
1. Glasgow Coma Scale (GCS)
2. The Average Value of Blood Pressure
3. Normal Pulse Rate
4. Muscle Strength scale
5. Activity Scale
6. Pain Scale
7. Human Body Temperature
8. Average Value of Visus
9. Sign Infection of Eye
10. Anxiety Level
11. Curiculum Vitae
ix
CHAPTER 1
INTRODUCTION
1.1. Background
Dyspepsia is symptom or syndrome consisting of pain or discomfort in
the epigastrium. Wich caused by diet and environmental factors,
secreation of acid, gastric motor function, gastric visceral perception,
psychology and Helicobacter pylori infection.
Majority (2015) on his book said that dyspepsia is a collection of

symptoms or syndrome consisting of pain or discomfort in the
epigastrium, nausea, vomiting, bloating, early satiety, a sense of full
stomach, belching, regurgitation and a burning sensation in the chest
radiating. According Annisa (in Djojoroningrat, 2001), the causes of
dyspepsia such as diet and environmental factors, the secretion of
stomach acid, gastric motor function, gastric visceral perception,
psychology and Helicobacter pylori infection.
WHO (2010) Gerd (18%) and peptic ulcer (13%) were the major causes
of organic dyspepsia; there were six cases (2%) of upper gastrointestinal
cancer (4 gastric carcinomas, 1 gastric lymphoma and 1 esophageal
adenocarcinoma ) characterizing a total of 96 (34%) patients as having
organic Dyspepsia. (Faintuch et al. BMC Gastroenterology
2014,14:19).Data obtained from western countries prevalence rate ranged
from 7-41%, but only 10-20% seek medical attention. Dyspepsia
incidence rate is estimated between 1-8% (Djojoningrat, 2009).
According to a population-based study in 2007, found an increased
prevalence of functional dyspepsia of 1.9% in 1988 to 3.3% in 2003.
Functional dyspepsia, in 2010, was reported to have a high prevalence
1
2
rate, is 5% of all visits to primary health care facilities. In fact, a study in

2011 in Denmark revealed that 1 in 5 patients who present with
dyspepsia turned out to have been infected with H pylori was detected
after further examination. ( Abdullah, M. &Gunawan, J 2012).
In Indonesia, an estimated nearly 30% of patients who come to the

common practice is patient complaints related to cases of dyspepsia. , it
turned out that patients with dyspepsia syndrome is quite high in
Indonesia. (Department, 2011) Concerning the health profile of 2010
states that dyspepsia ranks 5th of 10 major diseases with hospitalized
patients and No. 6 for patients who were treated roads.
Based on data obtained gastroenterologist clinic visits in approximately

20-40% of adults experience dyspepsia, while in public clinics only 2-
5%. The diversity figure this visit due to differences in perception about
the definition of dyspepsia (Rani, 2011).
According to the (Department, 2011), the number of patients hospitalized

patients with dyspepsia according to which the female sex as many as
15.122 cases or 61.18%, while in men as much as 9.594 or as much as
38.82% of cases the number of patients who come out as much as 24.716
people and the patient died as many as 166 people, according to national
health authorities in 2010 dyspepsia ranks sixth out of ten the number of
diseases in hospitals. (Ratna Rosita, 2011).
Based on the survey results at theBanjarmasin Ulin General Hospital,

especially in Tulip IIIC ward in 2015 amounted to 41 clients treated in
2014 ranks fifteenth in the number of diseases, now in 2015 amounted to
6 people hospitalized client ranks fifth twelve.
3
Based on the description and etiology above, the writer interested to lift
Dyspepsia optimal nursing care, because the researcher believe that many
people do not know about this case, the sign symptom, and the right
treatment, which make this disease always increasing based on data in
top 10 of disease in Banjarmasin Ulin General Hospital. It is hoped that
with correct nursing process, clients with Dyspepsia get the right
treatment. The writer took this case in Banjarmasin Ulin General
Hospital for the reason above.
1.2. Problem Formulation

The general purpose of the report is to apply a comprehensive nursing
care, physically, psychologically, in the client with a medical diagnosis of
dyspepsia in Banjarmasin Ulin General Hospital.
1.3. Special Purpose

In addition to general purpose, report writing nursing care also has
specify objectives include:
1.3.1. Able to perform assessment on a client with a case of dyspepsia.
1.3.2. Able to determine nursing diagnoses that appears on the client with
Dyspepsia case.
1.3.3. Able to determine nursing interventions that appear on the client
with dyspepsia.
1.3.4. Able to perform the implementation of nursing at the client with
Dyspepsia case.
1.3.5. Able to evaluate the results of nursing care that has been done on
the client with the case of dyspepsia.
1.3.6. Ability to prepare documentation of nursing care to clients with
cases of dyspepsia.
4
1.4. Benefits of Writing

1.4.1. For Client
Fulfillment of the psychosocial and spiritual needs of the clients
with cases of Dyspepsia and clients can achieve optimal
independence.
1.4.2. For Families
Families can participate and provide full support in the recovery
and biopsychosocial and spiritual needs of the clients with cases
of dyspepsia.
1.4.3. For Nurses
As a reference for application of the nursing care in a
comprehensive manner in order to be used for the benefit of
hospitals in providing nursing care to clients with cases of
dyspepsia.
1.4.4. For Hospital
As inputs, especially for stakeholders in Banjarmasin Ulin
General Hospital as a comparison between theoretical methods
and education obtained in the execution of the disease in men in
space on the client with a case of dyspepsia.
1.4.5. For Education
As input in improving the learning process in the future and a
benchmark in the implementation of nursing practice learning in a
comprehensive manner.
1.4.6. For Authors
Gain direct experience in performing nursing care with a
comprehensive approach to the nursing process and can determine
tips and art to improve the quality of nursing care to clients with
cases of dyspepsia.
5
1.5. Method of Nursing Care

In writing this report the author uses the case study method using the
nursing process approach that includes assessment, nursing diagnosis,
planning, implementation, evaluation and documentation. Studies by
collecting reference literature related to the cases raised. While the
method of data collection by interview, observation, physical examination
and supporting data.
1.6. Systematics of Writing

Chapter 1 Introduction, include the background, general and specific
objectives, benefits, scientific methods of nursing care, and systematic
writing. In writing this report the author uses the case study method using
the nursing process approach that includes assessment, nursing diagnosis,
planning, implementation, evaluation and documentation.
Chapter 2 theoretical background, include anatomy and physiology,

definition, classification, etiology, clinical manifestations,
pathophysiology, complications, supporting examination, medical
treatment, and prognosis. nursing theory consists of assessment, nursing
diagnosis, nursing interventions, and evaluation.
Chapter 3 the results of nursing care, consisting of illustration the case,

analysis of data, nursing diagnosis, nursing interventions, nursing
implementation, and nursing evaluation.
Chapter 4 Conclusions and suggestions.

CHAPTER 2
THEORETICAL REVIEW
2.1. Medical of Theoritical Review

2.1.1. Anatomy and Physiology of Stomach
Figure 1 features of the stomach
(http://ilmu-keperawatann. blogspot.com/2012/04/anatomi-fisiologi-sistem-
pencernaan.html)
Stomach
The stomach, which receives food from the esophagus, is located
in the upper left quadrant of the abdomen. It is capacity varies,
but in the adult it averages about 1.5 liters, although in some
individuals it may hold up to 4 liters.
6
7
Figure 2
(http://ilmu-keperawatann.blogspot.com/2012/04/anatomi-
fisiologi-sistem-pencernaan.html)
Structure
The stomach is divided into the cardiac, fundic, body, and pyloric
regions (figure 1 and 2). The cardiac region is a small region
around the opening from the esophagus. The fundus, the most
superior region, balloons above the cardiac region to form a
temporary storage area. The body is the main portion of the
stomach, which curves to the right and creates two curvatures.
The lesser curvature is concave and is directed superiorly and to
the right. On the opposite side, the convex greater curvature is
directed inferiorly and to the left. As the body approaches the ext
from the stomach, it narrows into the pyloric region. A circular
band of smooth muscle forms the pyloric sphincter, which acts as
a valve between the stomach and small intestine.
The muscular layer in the wall of the stomach has three layers,
instead of two as found in other parts of the digestive tract. The
additional third layer is innermost, located just under the
submucosa, and is formed of oblique muscle fibers. The next
muscle layer is the circular, and the outermost layer consists of
8
longitudinal muscle fibers. The oblique layers adds another

dimension to the mixing action of the stomach. When the stomach
is empty, the mucosa and submucosa show longitudinal folds,
called rugae (ROO-jee). These folds allow the stomach to expand,
and as it fills the rugae become less apparent.
Gastric Secretions
The mucosal lining of the stomach is simple columnar epithelium
with numerous tubular gastric glands. The gastric glands open to
the surface of the mucosa through tiny holes called gastric pits.
Four different types of cells make up the gastric glands: mucous
cells, parietal cells, chief cells, and endocrine cells. The secretions
of the exocrine gastric glands composed of the mucous, parietal,
and chief cells make up the gastric juice. Approximately 2 to 3
liters of gastric juice are produced every day. The products of the
endocrine cells are secreated directly into the blood stream and
are not a part of the gastric juice.
Mucous cell produce two type of mucus in the stomach. One type
is thick and alkaline and forms a protective coating for the
stomach lining. The oher type is thin and watery. It mixes with
the food and creates a fluid medium for chemical reactions.
Parietal cells secret hydrochloric acid and intrinsic factor. The
hydrochloric factor acid kills bacteria and provides an acidic
environment for the action of enzymes in the stomach. Intrinsic
factor aids in the absorption of vitamin B12. Chief cells secreate
pepsinogen, an inactive form of the enzyme pepsin. Hydrochloric
acid convert the inactive pepsinogen into the active enzyme
pepsin, which begin the chemical digestion of proteins. The
endocrine cells secreate the hormone gastric, which function in
the regulation of gastric activity.(Applegate, Edith, 2011)
9
2.2. Nursing Theoritical Review

2.2.1. Definition
Susanti (2010:19) said that Dyspepsia is a collection of symptoms
such as pain, feeling unwell upper abdomen that persist or
episodic accompanied by complaints such as feeling full while
eating, satiety, heartburn, bloating, belching, anorexia, nausea,
and vomiting.
In the same lime with susanti, Kumar A, Patel J, Sawant

P(2010:70) on his book said that Dyspepsia is a collection of
symptoms or signs comprises of discomfort or pain in upper
abdomen which persist or recur. Most commonly encountered
symptoms are epigastric pain, epigastric discomfort, early satiety,
fullness, bloating, and nausea.
In the same lime with susanti, Abdullah, Gunawan (2012:647) on

his book said that Dyspepsia is derived from the Greek, namely
dys- (bad) and -peptein (digestive) Based on the consensus of the
International Panel of clinical Investigators, dyspepsia defined as
pain or discomfort especially felt in the upper abdomen.
Furthermore, Majority (2015:73) on his book stated that

Dyspepsia is a collection of symptoms or syndrome consisting of
pain or discomfort in the epigastrium, nausea, vomiting, bloating,
early satiety, a sense of full stomach, belching, regurgitation and a
burning sensation in the chest radiating.
From the definition above, the writer concludes that dyspepsia is

collection of symptoms or syndrome consisting of pain or
discomfort in upper abdomen that persist or episodic
accompanied by complaints such as feeling full while eating,
10
satiety, heartburn, bloating, belching, anorexia, nausea, and

vomiting.
2.2.2. Etiology
Dyspepsia can be caused by many things (Harahap, 2009).
According Annisa (2009, quoted from Djojoroningrat, 2001), the
causes of dyspepsia such as diet and environmental factors, the
secretion of stomach acid, gastric motor function, gastric visceral
perception, psychology and Helicobacter pylori infection.
According Susanti (2011), dyspepsia syndrome is influenced by
stress levels, food and beverage irritating and history of disease
(gastritis and peptic ulcer disease).The higher the level of stress,
the higher the risk for the syndrome dyspepsia. Food and
beverage consumption habits, such as eating spicy, sour, tea,
coffee and carbonated beverages can increase the risk of the
appearance of symptoms of dyspepsia. The atmosphere is very
acid in the stomach can kill pathogenic organisms ingested with
food. However, when the gastric barrier has been broken, then the
atmosphere is very acid in the stomach will aggravate the
irritation of the stomach wall (Herman, 2004).
Common causes of dyspepsia include:

2.2.2.1. Burped-up stomach juices and gas (regurgitation or reflux)
caused by gastroesophageal reflux disease (GERD) or a
hiatal hernia.
2.2.2.2. A disorder that affects movement of food through the
intestines, such as irritable bowel syndrome.
2.2.2.3. Peptic (stomach) ulcer or duodenal ulcer.
2.2.2.4. An inability to digest milk and dairy products (lactose
intolerance).
11
2.2.2.5. Gallbladder pain (biliary colic) or inflammation

(cholecystitis).
2.2.2.6. Anxiety or depression.
2.2.2.7. Side effects of caffeine, alcohol, or medicines. Examples
of medicines that may cause dyspepsia are aspirin and
similar drugs, antibiotics, steroids, digoxin, and
theophylline.
2.2.2.8. Swallowed air.
2.2.2.9. Stomach cancer.
2.2.3. Pathophysiology
According to Majority (2015:75-76) various hypotheses have
been proposed to explain the mechanism of pathogenesis of
functional dyspepsia, among others: gastric acid secretion,
gastrointestinal dysmotility, visceral hypersensitivity, autonomic
dysfunction, diet and environmental factors, psychological.
2.2.3.1. Gastric acid secretion.
The gastric juice contains various substances.
Hydrochloric acid (HCl) and pepsinogen is a
compound in the gastric juice. The concentration of
acid in gastric juice is very concentrated so may cause
damage network, but in normal people do not
experience irritation of the gastric mucosa due in part
to gastric fluid containing mucus, which is a gastric
protective factor. Cases with functional dyspepsia is
suspected increase in sensitivitygastric mucosa to acid
that causes discomfort in the abdomen. Increased
sensitivity of the gastric mucosamayoccur due to
irregular eating patterns. Irregular eating patterns will
make it difficult to adapt in the stomach gastric acid
secretion expenditure. If this goes on for a long time,
12
the production of acidExcessive gastric mucosal wall

so it can irritate the stomach
2.2.3.2. Dysmotility Gastrointestinal.
Some meta-analysis study investigate functional
dyspepsia and emptying disorders hull, found 40% of
patients with functional dyspepsia have 1.5 times
slower emptying of normal patients.
2.2.3.3. Visceral hypersensitivity.
Intestinal wall has various receptors, including
receptors chemical, mechanical receptors, and
nociceptor. Study using the intragastric balloon
showed that 50% of the population of functional
dyspepsia already incurred pain or discomfort in the
abdomen on the balloon inflation with lower volume
than the volume that causes pain in the control
population.
2.2.3.4. Disorders of gastric accommodation.

Under normal circumstances, when food enters the
stomach occurs relaxation of the fundus and gastric
corpus without increasing the pressure in the stomach.
Gastric accommodation is mediated by serotonin and
nitric oxide via the vagus nerve from the enteric
nervous system. It was reported that in patients with
functional dyspepsia decreased postprandial fundus
relaxation ability in 40% of cases with
gastricscintigraphy examination and ultrasound
(USG).
2.2.3.5. Helicobacter pylori.
Role of Helicobacter pylori infection in functional
dyspepsia are not yet fully understood and accepted.
13
Incidence of H. pylori infection are around 50% in

functional dyspepsia and did not differ between
groups of healthy people.
2.2.3.6. Diet.
Patients with functional dyspepsia tend to change the
diet because of the intolerance of some foods.
Especially fatty foods has been associated with
dyspepsia.
2.2.3.7. Psychological factors.
Reported a decrease in gastric contractility which
precede nausea after central stressful stimulus. But the
correlation between psychological stress factors of
life, autonomic function and motility remains
controversial.
14
Pathway
Changes in eating patterns
irregular
Decreased food intake
Stomach empty
Increased HCL production
Erode stomach wall
dyspepsia
Afferent nerv Stimulated stomach nerv Irritation stomach wall
Medulla spinalis hypothalamus Uncomfortable feeling in

epigastric
Thalamus Nausea
anorexia
Cerebral cortex HCL irritate stomach wall

Old anorexia
(hypermetabolic)
Afferent nerv oesophageal
decrease in ATP
formation
Pain dysphagia
Activity
fatigue
intolerance
Nutrition less than body
Source: J MAJORITY (2015:75-76) requirement
15
2.2.4. Sign and symptom

Dyspepsia is a common condition and usually describes a group
of symptoms rather than one predominant symptom. These
symptoms include:
2.2.4.1. Belly pain or discomfort.
2.2.4.2. Bloating.
2.2.4.3. Feeling uncomfortably full after eating.
2.2.4.4. Nausea.
2.2.4.5. Loss of appetite.
2.2.4.6. Heartburn.
2.2.4.7. Burping up food or liquid (regurgitation).
2.2.4.8. Burping.
Most people will experience some symptoms of dyspepsia within

their life times.
2.2.5. Diagnostic examination

According to Murdani Abdullah, Jeffri Gunawan (2013:6-7)
Various kinds of illnesses can cause similar complaints, such as
dyspepsia syndrome, therefore dyspepsia just a collection
symptoms and diseases in the digestive tract, it is necessary to
ensure the disease.
To ensure the disease, there should be some checks, in addition to
physical observation, also need to be examined: laboratory,
radiologic, endoscopic, Ultrasound, and others:
2.2.5.1. Laboratory examination test
Laboratory tests need to be done more emphasized to
rule out organic causes such as: chronic pancreatitis,
diabetes mellitus, and others. In the laboratory of
functional dyspepsia usually results within normal
limits.
16
2.2.5.2. Radiological
Radiological examination much support dignosis a
disease in the food channel. At the very least need to be
radiologically against eating top tract, and should use a
double contrast.
2.2.5.3. Endoscopy (Esofago-Gastro Duodenoskopi)
In accordance with the definition that the functional
dyspepsia, a picture or a normal endoscope is not very
specific.
2.2.5.4. USG (ultrasonography)
Is a non-invasive diagnostic, lately more and more used
to help determine the diagnostic of a disease, let alone
these tools do not cause side effects, can be used at any
time and on condition that the client can be exploited
heaviest item.
2.2.5.5. Gastric emptying time
Can be done with scintigafi or with radiopaque pellets.
In the gastric emptying of functional dyspepsia are in
30-40% of cases.
2.2.6. Medical treatment

According to Abdullah, Gunawan (2013:6)
2.2.6.1. Non-pharmacological management
2.2.6.1.1. Avoiding foods that can increase stomach
acid.
2.2.6.1.2. Avoiding risk factors such as alcohol, spicy
foods, excessive drug, nicotine cigarettes,
and stress.
2.2.6.1.3. Diet control.
17
2.2.6.2. Pharmacologic management namely:

Until now there has been no satisfactory treatment
regimens, especially in anticipation of recurrence. This is
understandable because pross pathophysiology is still
unclear. It was reported that up to 70% of cases of DF
with an unresponsive to placebo.
Medicines are given include antacid (to neutralize
stomach acid) class of anti cholinergic (inhibiting gastric
acid spending) and prokinetic (to prevent vomiting)
2.2.7. Non Medical Treatment

Can make changes to lifestyle to help relieveing symptom of
dyspepsia. Here are some things to try:
2.2.7.1. Change eating habits.
2.2.7.2. Its best to eat several small meals instead of two or
three large meals.
2.2.7.3. After eat, wait 2 to 3 hours before lie down. Late-night
snacks arent a good idea.
2.2.7.4. Chocolate, mint, and alcohol can make dyspepsia
worse. They relax the valve between the esophagus and
the stomach.
2.2.7.5. Spicy foods, food that have a lot acid (like tomatoes
and oranges) and coffe can make dyspepsia worse in
some people. If symptom are worse aftereat a certain
food, may want to stop eating that food to see if
symptom get better.
2.2.7.6. Do not smoke or chew tobacco.
2.2.7.7. If get dyspepsia at night, raise the head of bed 6 to 8
inches by putting the frame on bocks or placing a foam
wedge under the head of mattress. (adding extra pillows
does not work.)
18
2.2.7.8. Do not wear tight clothing around your middle.

2.2.7.9. Lose weight if you need. Losing just 5 to 6 pounds can
help.
2.2.7.10. Treatment depends on what is causing the problem. If
no specific cause is found, treatment focuses on
relieving symptom with medicine.
(http://www.webmd.com/digestive-disorders/tc/dyspepsia-
topic--overview (accessed on 4th of june 2015)).
2.2.8. Complications
Patients with dyspepsia syndrome for many years can lead to
complications that are not light. One of these complications
dyspepsia is wound in the stomach wall or widen depending on
how long the hull exposed to stomach acid. If things continue to
happen wound dyspepsia will be deeper and can cause
gastrointestinal bleeding complication that is characterized by the
occurrence of vomiting blood, which is a sign that arise later.
Initially the patient would have had a bowel movement first black
which means that existing initial bleeding. But the most feared
complication is the occurrence of gastric cancer sufferers who
require surgery (Wibawa, 2006).
2.2.9. Prognosis
Mahadeva et al. (2011) found that patients with functional
dyspepsia have a lower quality of life prognosis compared with
individuals with organic dyspepsia. Moderate to severe levels of
anxiety were also more often experienced by individuals
dyspepsia functional.25 Further investigation revealed that
patients with functional dyspepsia, especially refractory to
treatment, have a high tendency to experience depression and
psychiatric disorders.
19
2.2.10. Nursing care plan

2.2.10.1. Assessment
Based on Muttaqin, Arif (2012:209-243) the
assessment of client with dyspepsia syndrome are:
a. Anamnesis
During the collecting history, the nurse asks about the
signs and symptoms in patients. In summary assessment
of the stomach, include the following.
1. Does the patient have heartburn, cant eat,
nausea, or vomiting?
2. What are symptoms occur at any time, before or
after meals, after digesting spicy foods or
irritants, or after ingesting certain drugs or
alcohol?
3. What are the symptoms associated with anxiety,
stress, allergies, eating or drinking to much, or to
fast eating?
4. How symptoms reduced?
5. Is there a history of previous stomach or gastric
surgery?
History of peptic ulcer pain (presence of excavation /
hollow area in the mucosal lining of the stomach,
pylorus, duodenum, esophagus) will client complained
with dull pain, like a stabbing or burning sensation in
the epigastric middle or at the back. It is believed that
the pain occurs when the acidic contents of the stomach
and duodenum, causing increased erosion and stimulate
the nerve endings are exposed. Another theory indicates
that the lesion contact with acids stimulate local reflex
mechanisms that initiate contraction of the surrounding
small intestine. Pain is usually relieved by eating
20
because food neutralizes the acid or by using alkali.

However, when the stomach is empty or alkali
unusable, back pain arises. Sharp local tenderness can
be eliminated by providing gentle pressure on the
epigastric or slightly to the right of the midline. Some
of the symptoms decreased with local pressure on the
epigastric.
Assessment of dietary history plus good type of diet

eaten for 72 hours will be very helpful. Complete
history is very important in helping nurses to identify
whether excess diet or diet frivolous known, associated
with current symptoms, whether anyone else on the
client environment have similar symptoms, whether the
patient is vomiting blood, and whether elements of the
known causes swallowed.
b. Physical examination
1) General condition
After anamnesis performing, nurse clarify the
findings of history by conducting a physical
examination. Signs that are known for physical
examination include is obtained abdominal pain,
if there is dehydration (changes in skin turgor,
dry mucous membranes), and evidence of
systemic disorders resulting from gastric
disorders.
1. Consciousness level.
2. Vital sign.
(Muttaqin, Arif, 2012:209-243)
2) Skin
1. Lesions, markers of inflammation.
21
2. Good skin turgor, quickly re <1 sec.

3. skin moisture.
4. symptoms of cyanosis.
3) Head
1. Hair color and distribution.
2. Dirt scalp / dandruff.
3. Symmetrical shape, there are no lumps.
4) Sight
1. The movement of the eyeball,
conjunctiva.
2. Reflex to light.
3. Presence or absence of visual
impairment (Visus).
5) Mouth
1. Mucosa of the lips and tongue color.
2. gum color.
6) Chest/ Respiration/ Circulation
1. Shape of the chest and chest wall
retractions.
2. Fremitus dextra vocals and the left.
3. 1 and 2 single sound, presence or
absence of additional breath sounds
audible.
7) Abdomen
1. The shape of the abdomen, bloating.
2. Left hypogastric region tenderness,
palpable enlarged liver or not.
3. Timpany sound, bloating.
4. Increased bowel.
8) Upper extremity and lower extremity
22
1. Acral warm or not, form dextra hand and

the left, the number of fingers, whether
or not the restriction of movement of the
upper limb.
2. Shape of the foot, there are no symptoms
/ signs of edema, presence or absence of
restriction of movement of the lower
limb.
c. Assessment of psycho-social problems-and spiritual-
cultural. According to Shobirin, M. et all(2014)
A. Activity and Rest
At home : activity and exercises habits, time
and duration of activity.
In the hospital : activity ad excercises habits while
in the hospital.
B. Personal Hygient
At home : habits of bathing, shampooing,
brushing teeth (personal hygiene).
In the hospital : ability activities, activity
disturbance in the hospital.
C. Nutrition
At home : eating and drinking habits,
abstinence from eating, foods that
cause allergies, the total of drink and
type of beverage every day.
In the hospital : eating disorders, diet given.
23
D. Elimination
At home : habits or pattern of bowel and
bladder, complaints or disorders
when eliminations.
In the hospital : bowel and urinate patterns,
elimination pattern disorders.
Formula to calculate fluid balance:

IWL formula:
In normal temperature 36,5C - 37C
IWL = (15 x BB)
24 hours
In abnormal temperature over than>37C

[(10% x CM) x amount of temperature rise]+
normal IWL
24 hours
E. Psychology
1. Client's feelings after experiencing this
problem.
2. How to deal with those feelings.
3. Plans client after the problem is resolved.
4. If this plan is not resolved.
F. Social
1. Activity or client role in society.
2. Environmental habits unwelcome.
3. How to cope.
4. Client views on social activities in the
neighborhood.
24
G. Culture
1. Cultural followed by client.
2. The cultural activities.
3. Objections in following the culture.
H. Spiritual
1. Summary of worship is usually do everyday.
2. Religious activity is usually do.
3. Activity of worship which now cant do.
4. The result of the client's feelings cant
implement it.
5. Efforts clients overcome these feelings.
6. What client confidence about the events /
health problems now being experienced.
2.2.10.2. Nursing diagnosis

Based on NANDA (2012-2014) it can be conclude that
nursing diagnose for client with dyspepsia are:
a. Acute pain related to biological injury agent
secondary to dyspepsia.
b. Imbalance nutrition: less than body requirement
related to inability to absorb nutrients.
c. Activity intolerance related to imbalance between
supply and oxygen demand.
d. Risks related to lack of fluid volume is not enough
fluid intake and excessive fluid loss due to vomiting.
e. Anxiety related to treatment.
2.2.10.3. Planning
a. Acute pain related to biological injury agent
secondary to dyspepsia.
Purpose: problem of acute pain can be resolved
25
Intervention:
Independent:
1. Assess the cause and characteristic of pain
2. Maintain bed rest, provide quiet environment.
3. Monitor the vital sign such as blood pressure,
pulse, respiration rate and temperature.
4. Recommend to the client for take a deep breath or
the other activity that cant increase the pain.
5. Collaborating administrator medications as
indicated; analgetic.
6. pain relief
a. Assess the level of pain and the comfort of the
client.
b. Avoid foods and beverages that can irritate the
gastric mucosa.
b. Imbalance nutrition: less than body requirement

related to inability to absorb nutrients.
Purpose: client can eat the daily nutrition in
accordance with the level of activity and metabolic
needs.
Intervention:
Independent:
1. Determine daily calorie needs a realistic and
adequate. Consult with a nutritionist.
2. Weigh the weight every day; monitor the results
of laboratory tests. Explain the importance of
adequate nutritional intake. Discuss with the
client regarding the intake targets for each major
meal and snack.
26
3. Encourage clients to use the spices to help the

taste and aroma of food.
4. Encourage or help clients to rest before eating.
5. Suggest to clients family to bring the client's
favorite food.
6. Try supplements are available in forms (powder,
liquid, pudding).
7. Improving nutrition
a. Assess for nausea, vomiting, heartburn pain
and fatigue.
b. Avoid foods / beverages containing caffeine
because caffeine is a central nervous system
stimulant that increases the activity of the
stomach.
c. Avoid the use of alcohol and nicotine.
c. Activity intolerance related to imbalance between

supply and oxygen demand.
Purpose: individuals will continue its activities to
achieve the scale of activity 0-1.
Intervention:
Independent:
1. Measure pulse, blood pressure, and breathing at
rest.
2. Consider the frequency, rhythm, and quality (if
signs of abnormal-ie., Pulse> 100- consult a
doctor / nurse practitioners on the benefits of
increasing the activity).
3. Measure vital signs immediately after the
activity: measuring the pulse for 15 seconds and
27
multiply by 4 and not by calculating a full

minute).
4. Give client rest for 3 minutes; measuring vital
signs back. Compare the results with vital signs at
the break.
5. Stop the activity if the client responds to the
activity:
a. Complaints of chest pain, dyspnea, vertigo or
confusion
b. Pulse frequency decreases
c. Systolic rate not increased
d. Systolic blood pressure decreased
e. Diastolic rate increase 11 mmHg
f. Decreased respiratory function
6. Reduce the intensity, frequency or duration of
activity if:
a. It took more than 3-4 minutes for the pulse
back within 6 resting pulse rate frequency
b. Respiratory rate increased dramatically after
activity
c. There are other signs of hypoxia, (eg,
confusion, vertigo)
d. Risks related to lack of fluid volume is not enough

fluid intake and excessive fluid loss due to vomiting.
Purpose: individuals will show the status dehidration
continuous, with urine output> 5 ml / kg / h.
Intervention:
1. Increase fluid balance.
a. Monitor the input and output of fluid every
day to detect the early signs of dehydration.
28
b. Assess the value of electrolytes (sodium,

potassium, chloride) every 24 hours to detect
early indicators of imbalances.
2. skin turgor monitor each shift and record losses.
3. check mucous membranes every day.
4. provide and monitor parenteral fluids as
recommended.
5. monitor and report the value electrolyte
abnormality.
6. provide and monitor treatment, such as anti
ematik and anti diarrheal.
e. Anxiety related to treatment.

1. assess the level of anxiety: mild, moderate,
severe, panic.
2. provide comfort and peace of heart.
3. get rid of excessive stimulation (ie., bring the
client to a more quiet room); limit contact with
others-client or family is also worried.
4. if anxiety has been sufficiently reduced for
ongoing learning process, help clients identify
anxiety to start learning or problem solving.
5. teach stopper anxiety that can be applied if the
situations that cause stress cant be avoided.
6. Reduce anxiety
a. Use approaches to assess the patient and
answered all questions as completely as
possible.
b. Explain all procedures and treatment in
accordance with the client's level of
understanding.
29
CHAPTER 3
NURSING CARE REPORT
3.1. Assessment
Based on the assessment conducted on Monday, June 1st 2015, the
information gathered are clients identity. Clients name is Mr. S. He is
male, 28 years old, and he lives in Teluk Tiram Street Banjarmasin. His
last education was junior high school, he is a Muslim, and occupation is
construction worker. He has married. His ethnic is bugesse and his
nationality Indonesian. Clients medical record is 1-11-xx-xx. He got
hospitalized on Thursday, May 28th 2015 with medical diagnose of
dyspepsia.
Client next of kin is Mrs. S. She is female and her age is 50 years old.
She lives in Teluk Tiram and her occupation is housewife. She is clients
mother.
3.2. History Of Health

3.2.1. Main Complain
Based on the assessment conducted on Monday, June 1st 2015,
client said that he felt abdominal pain in the right middle and left
upper and the times is sometimes. Client said that his pain
unbearable and he felt heat and stabbing pain.
3.2.2. History of current disease
Client said that he blood vomit since 5 days ago or in Saturday,
May 23th 2015 in a day. He vomited 4 times and the color of
blood was fresh blood and mixed with another meal. He felt
dizziness since 3 days ago, gastric disease since 5 days ago in
Saturday, May 23rd 2015, and he expeienced breathlessness since
3 days ago or in Monday, May 25th 2015. Then, the client was
encouraged go to the hospital. Client was brought by his family to
30
the Banjarmasin Ulin General Hospital to do re-examination.

After re-examination, it was found that client diagnosis is
Dyspepsia. Now client is treated in Tulip IIIC ward.
3.2.3. History of previous disease
Client said that he has ever got the same disease 3 days ago.
Client did not have infectious disease such as tuberculosis, HIV,
etc. client also did not have heredity disease such as heart failure,
diabetic mellitus, leukemia etc.
3.2.4. History of family disease
Client said that in his family had ever got this kind of disease. He
odded that in his family, there was no history of contagious and
heredity disease such as hepatitis, heart failure, diabetic mellitus,
etc.
3.3. Physical Examination

3.3.1. General Condition
Client general condition looked weak, client looked grimace and
sometimes client consciousness level is composmentis with GCS :
3.3.1.1. E4 V5 M6
Exp: 4. Spontaneous eye response
5. Spontaneous verbal response
6. Motoric is following orders
3.3.1.2. Client looked just lying on the bed with vital sign:
BP : 110/70 mmHg
P : 104x/ minute
RR : 22x/ minute
Temp : 37C
31
3.3.1.3. Antropometri data:

BW : 60 kg
BH : 170 cm
IBW :
= 170 100 (170-100 x10%)
= 70 7.0 (70+7.0)
= 63 > 77 kg
3.3.2. Skin
Clients skin looked clean, the skin color is tanmed. His skin is
elastic and responded well to pinch which was can back before 2
second and there is no oedema on client skin, client skin looked
dry but there was no injury bleeding lesions or inflammation.
3.3.3. Head and Neck
Clients head and neck looked symmetric. Head and hair were
clean enough and the color of the hair is black. There was no
dandruff on clients hair and there was no limited movement on
client neck. There was no enlargement of lymph gland.
3.3.4. Sight and Eyes
Clients eye structure was symmetric. Conjunctiva looked anemic
sclera does no looked abnormality. Client can move his eyeball
normally and symmetricly. Clients visual function was good
characterized by an client ability to read an a book and client
using sight aids sometimes.
3.3.5. Olfactory and Nose
Clients nose shape was symmetric. With no secreate in clients
nose. There was no bleeding on his nose. There was no trauma or
inflammation on clients nose. Client olfactory was good and
looked using O2 with 3 ltr and using nasal canule.
32
3.3.6. Hearing and Ears

Client ears structure were symmetric. The ears looked dirty, but
the hearing function was good characterized by an ability to
response nurse question and client didnt use hearing aids.
3.3.7. Mouth and teeth
Mouth function looked good and clean enough, but his lips was
dry there wasnt broken teeth, no bleding and no trauma. Client
can speak with nurse and his family. Client ability to chew food
was good but he couldnt swallow it because when he tried to
swallow, he always vomited. Clients mucosa color is white.
3.3.8. Chest and Respiration
Client chest structure looked symmetric. Client looked
breathlessness but he doesnt use ventilator vascular breath sound.
CRT can be back in less than 2 seconds. There was no ronkhi on
client respiration sound. Client respiration was 22x/m, tactile
fremitus is symmetric on both of side, sounds breath is vesicular,
and client chest percussion is sonor.
3.3.9. Abdominal
I : Client abdomen looked oedema, client always hold his left
abdomen because he felt heat and pain on his stomach.
Clients abdominal circumferences is 50 cm
A : Clients bowel sound is10x/m
P : Clients abdominal sound is dull
P : Clients abdomen is mass hard such as stone and the size
of clench in the left upper quadrant, there is pressure pain in
the abdomen.
Clients abdominal palpable hard cause of the disease. Moreover,
client felt pain on his abdomen when nurse do the palpation
examination with scale of pain is 3 (moderate)
P :abdominal pain and can increase pain when get pressure
Q :feels like burn
33
R : left abdomen
S : 3 (severe)
T :long pain come is 3 minute and can decrease when not get
pressure.
3.3.10. Genetalia and Reproduction
Client is male and he has married and has 1 children. Client did
not use catheter. Client elimination is good, client does not feel
pain when urinate, and client had no problem about reproduction
problem.
3.3.11. Upper and Lower extremities
Client upper and lower extremities is complete upper symmetric,
looked client use infuse with Nacl + Ds with 20 dpm and client
also get blood transfusion, client said that felt pain on his left
chest with :
Scale of muscle is
4444 4444
4444 4444
Exp:
3.3.11.1. Explanation for muscle strength
0 : palize full
1 : contraction very weak without look join move
2 : joint can move but cant fight gravitation
3 : full joint and can fight gravitation
4 : less than normal, can fight gravitation
5 : full muscle power
34
3.4. Physical, Psycological and Spiritual Needs

3.4.1. Activity and Rest
3.4.1.1. At home
Client said that he always sleep regularly from 9 pm till 6
am client also took a rest in afternoon about 2 hours.
Client did his activity by himself client activity in the
home is as verified.
3.4.1.2. At hospital
Client said that he always sleep but sometimes woke up
cause of pain come client sleep 8 hours at night and 2
hours at afternoon. And client activity helped by nurse
and family the scale of activity is 2 (helped by other
people).
Explanation of activity scale
1 : independent.
2 : need help and monitoring by others.
3 : need the simple help and monitoring by others.
4 : need help, monitoring by others, and the aids stuff.
5 : totally dependent.
3.4.2. Personal Hygiene

3.4.2.1. At home
Client said that he always took a bath twice a day,
brushed his teeth 3 times a day and cutted his nail when
nails were dirty.
Client said that he just wiped by his family everyday.
Client brushed his teeth 1 times/ day with the help of his
family. Client didnt get his hair shampooed and nail get
cut, client skin is clean enough, no odor on client body.
35
3.4.3. Nutrition
3.4.3.1. At home
Client said that always ate 3x a day with varied menu of
foods and sometimes add with snack. He drunk 7/8
glassess a day.client had no allergic to the food.
Client said that he drunk water about 4 glassess, and he
just ate porridge when he was in hospital with frequency
of ate 3 spoones.
a. Intake
1) Oral : 300 cc/24 hours (diet entresol 1x300 cc)
2) Parenteral : 2400 cc/24 hours
3) Inj : 1.027 cc/24 hours
3.4.4. Elimination
3.4.4.1. At home
Client said that urinate 6x/day and defecate 2x/day and
client said that hes never get disturbance in defecating.
Client said that he often defecated cause of he get
diarrhea and he defecated more than 5 times.
a. Output
IWL : 15 cc x kg of body weight/24
15 cc x 60 kg/24
37,5 cc x 24 hours
900 cc
Urine : 2000 cc/24 hours
Vomit : 40 cc
Feces : 300 cc
36
Fluid balance
Input volume:
oral : 300 cc
parenteral : 1000 cc
inj : 1.027 cc
WM : 300 cc + (5 cc x 60 kg)
: 2.627
Output volume:
Vomit : 40 cc
Feces : 300 cc
IWL : 900 cc (15 cc x 60 kg/24 hours)
: 3.240 cc
Fluid Balance : 3.240 2.627

: +613 cc
3.4.5. Sexuality
Client is male and his age is 28 years old. He has 1 children and
he hasnt got disturbance in sexuality.
3.4.6. Psychosocial
Client do not have problem with environment and society because
his mother and his brother worried about client condition. Client
relationship with family is good, clients relationship with the
other patient is also good, and clients relationship with health
workers is also good. Client is open with nurse and tells what he
felt.
3.4.7. Spiritual
Client is Muslim and he always pray for his health.
37
3.5. Focus data

3.5.1. Subjective data
1. Client said that he felt blood vomit.
2. Client said that he started vomit since 5 days ago.
3. Client said that he felt dizziness since 3 days ago.
4. Client said that he felt gastric since 5 days ago.
5. Client said that he felt breathlessness since 3 days ago.
6. Client said that he felt anorexia when eat.
7. Client said that he ate just 3 spoones.
8. Client said that he defecate more that 3 times.
9. Client said that he felt diarrhea.
10. Client said that he felt pain on his abdomen.
3.5.2. Objective data

1. Inspection
a. Client condition looked weak.
b. Client always go to toilet more than 3 times.
c. Client cant ate well just eat 3 spoones.
d. Client looked breathlessness.
e. Client looked use O2 3 ltr nasal canule.
f. Client looked use chest respiration.
g. Client abdomen palpable hard.
h. Client grimace when his abdomen get pressure.
i. P : abdominal pain and can increase the pain when get
pressure
Q :feels like burn
R : left abdomen
S : 3 (severe)
T : long pain come is 3 minute and can decrease when
not get pressure
38
j. Muscle scale is.

4444 4444
4444 4444
k. Client drunk just 4 glassess a day.

l. Client respiration frequency 22x/m.
m. Intake
Oral : 300 cc/24 hours
Parenteral : 2400 cc/24 hours
n. Output
IWL : 15 cc x kg of body weight/24 hours
15 cc x 60 kg/24 hours
37,5 cc/24 hours
Fluid balance
Input volume:
oral : 300 cc
parenteral : 1000 cc
inj : 1.027 cc
WM : 300 cc + (5 cc x 60 kg)
: 2.627 cc
Output volume:
URINE : 2000 cc/24 hours
Vomit : 40 cc
Feces : 300 cc
IWL : 900cc (15 cc x 60 kg)
: 3.240 cc
FB : 3.240 2.725
: +613 cc
o. Client could sit and walk with helped by his family.
p. Client activity scale is 2 (helped by another people).
39
2. Palpation
a. When palpable on client abdomen there is oedema
and palpable hard on his abdomen
b. When the palpated there is pressure in client abdomen
3. Percussion
a. Client abdominal sounds dull
4. Auscultation
a. Peristaltic sound is 10x/minute.
3.6. Supporting Data

Table 3.1 Supporting data on Laboratory test on June, 1st 2015
Examination Result Normal Result Unit Method
Haematology
Haemoglobin 2.7* 14.00-18.00 g/dl colorimetric
Leukosite 6.4 4.0-10.5 Thousand Impedance
/ul
Eritrosite 1.11* 4.50-6.00 Milion/ul impedance
Hematokrite 9.1* 42.00-52.00 Vol % Analyzer calculates
Trombosite 152 150-450 Thousand Impedance
/ul
RDW-CV 22.7* 11.5-14.7 % Analyzer calculates
MCV, MCH, MCHC
MCV 82.6 80.0-97.0 Fl Analyzer calculates
MCH 24.3* 27.0-32.0 Pg Analyzer calculates
MCHC 29.6* 32.0-38.0 % Analyzer calculates
Count of Kin
Gran % 76.8* 50.0-70.0 % Impedance
Limfosit % 16.4* 25.0-40.0 % Impedance
MID % 6.8 4.0-11.0 % Impedance
Gran # 5.00 2.50-7.00 Thousand Impedance
/ul
Limfosit # 1.0* 1.25-4.00 Thousand Impedance
/ul
MID # 0.4 Thousand Impedance
/ul
Banjarmasin Ulin General Hospital

40
Table 3.2 Laboratory result on June 4th 2015

Haematology
Leukosite 2.8* 4.0-10.5 Thousand Impedance
/ul
Trombosite 109* 150-450 Thousand Impedance
/ul
RDW-CV 16.2* 11.5-14.7 % Analyzer calculates
MCV, MCH, MCHC
MCH 28.7 27.0-32.0 Pg Analyzer calculates
MCHC 34.4 32.0-38.0 % Analyzer calculates
Count of Kin
Basofil % 0.5 0.0-1.0 %
Eosinofil % 6.6* 1.0-3.0 %
Gran % 53.9 50.0-70.0 % Impedance
Limfosit % 23.1* 25.0-45.0 % Impedance
Monosit % 15.9* 3.0-9.0 %
Basofil # 0.01 <1 Thousand
/ul
Eosinofil # 0.19 <3 Thousand
/ul
Gran # 1.51* 2.50-7.00 Thousand Impedance
/ul
Limfosit # 0.7* 1.25-4.0 Thousand Impedance
/ul
Monosit # 0.45 0.35-1.00 Thousand
/ul
IMUNO-SEROLOGI
SI 38.3
TIBC 274
ST 14
FERITIN 16.06 12.00-300.00 Ng/ml Step EIA sandwich +
EU
Banjarmasin Ulin General Hopital

41
Table 3.3 Laboratory result on June 6th 2015

Haematology
Leukosite 3.6* 4.0-10.5 Thousand Impedance
/ul
Trombosite 161 150-450 Thousand Impedance
/ul
RDW-CV 16.7 * 11.5-14.7 % Analyzer calculates
MCV, MCH, MCHC
MCH 25.7* 27.0-32.0 Pg Analyzer calculates
MCHC 30.3* 32.0-38.0 % Analyzer calculates
Count of Kin
Gran % 61.1 50.0-70.0 % Impedance
Lymfosite % 21.3* 25.0-40.0 % Impedance
MID % 17.6* 4.0-11.0 % Impedance
Gran # 2.20* 2.50-7.00 Thousand Impedance
/ul
Lymfosite # 0.8* 1.25-4.00 Thousand Impedance
/ul
MID # 0.6 Thousand/ul Impedance
THROMBIN TIME
Hasil PT 10.1 9.9-13.5 Second Nephelometri
INR 0.90 - Nephelometri
PT Normal control 11.4 - - Nephelometri
APTT Result 20.8* 22.2-37.0 Second Nephelometri
APTT Normal 26.1 - Nephelometri
Control
SCIENCE
LIVER
Protein total 5.1* 6.2-8.0 g/dl BCG
Albumin 3.1* 3.5-5.5 g/dl Biuret
ELEKTROLYTE
Natrium 140.3 135-146 Mmol/l ISE
Kalium 3.3* 3.4-5.4 Mmol/l ISE
Chlorida 03.1* 95-100 Mmol/l ISE
Banjarmasin Ulin General Hospital

42
3.7. Pharmacological Therapy
Table 3.4 PharmacologicalTherapy

Drugs Dose Route Kind of drugs patient
IVFD Nacl + DS 20 dpm IV Line Electrolyte Mr. S

Neurobion 5000 2x10 mg Inj Vitamin B1 Mr. S
Sucralfat 2x1 cth SYR Duodenum Sore Mr. S
Antrain 3x2mg Inj Anti ulcer Mr. S
Loratadine 2x10 mg Inj Anti alergi Mr. S
As. Traksenamat 3x300 mg Inj anti-fibrinolitik Mr. S
Ranitidine 2x25 mg Inj H2 receptor Mr. S
KSR 2x600 mg Po hypokalemia Mr. S
Blood Transfusion A 2x1 kolf Blood Mr.S
Line
The result of doctor prescription
3.8. Data Analysis

Table 3.5 data analysis
Data Problem Etiology
Subjective data: Acute pain Agent physical injury
Client said that he secondary to disease
felt pain on his process (dyspepsia)
abdomen.
Client said that he
felt dizziness.
Client said that he
felt gastric 3 days
ago.
P :abdominal pain
and can increase the
pain when get
pressure.
Q :feels like burn.
R : left abdomen.
S : 3 (moderate).
T :long pain come is
3 minute and can
decrease when not
get pressure.
Objective data
Client abdomen
palpable hard.
43
Client looked
grimace when his
abdomen get
pressure.
Client condition
looked weak.
Risk factor Risk for lack of fluid

IWL : 15 cc x kg of volume related to not
BW enough fluid intake and
15 cc x 60 kg excessive fluid loss due
900 cc/24 hours to vomiting
Urine : 2000 cc/24
hours
Client just drunk 4
glassess.
Client said that he
often go toilet cause of
diarrhea.
Client pulse : 104x/m
fast and irregular.
Client oral mucosa is
dry.
Input : 2.725 cc.
Output : 3.240 cc.
Parenteral : 1000 cc/24
hours.
Subjective data Imbalance Nutrition Less of appetite
Client said that he felt less than body
vomit since 5 days ago. requirement
Client said that he felt
anorexia when eat.
Client said that he eat

just 3 spoons.
Objective data
Client cant eat well
just eat 3 spoone.
Client condition looked
weak.
Client drunk just 4
glassess a day.
Antropometri data
BW : 60 kg
IBW : 63 -77 kg
Client pulse is 104x/m
fast and irregular.
44
Hb : 2.7 g/dl
Leukosit: 1.11
thousand/ul
Hematokrit: 9.1vol%
Subjective data Ineffective breathing pain
Client said that he pattern
felt breathlessness
since 3 days ago.
Objective data
Client looked
breathlessness.
Client looked use
O2 3 ltr nasal
canule.
Client looked use
chest respiration.
Client respiration
frequency
22x/mbreathrhytm
irregular and
shallow.
Client using nostril.
3.9. Problem priority

3.9.1. Acute pain related to Agent physical injury secondary to disease
process (dyspepsia).
3.9.2. Risk for lack of fluid volume related to not enough fluid intake
and excessive fluid loss due to vomiting.
3.9.3. Imbalance nutrition less than body requirement related to less of
appetite.
3.9.4. Ineffective breathing pattern related to pain.
45
3.10. Intervention
Table 3.6 intervention
No Nursing Planning
Diagnose Purpose Intervention Rational
1. Acute pain After do nursing 1. ask client to tell 1. continueing
related to action abdominal his pain, causes, assessment
Agent physical pain can be and can modified
injury solved in 1x30 characteristic of as nursing
secondary to minutes with pain. care plan.
disease criteria: 2. Obs vital sign. 2. To know
process o Client can generally
(dyspepsia) control pain. client
o Client report condition of
the pain was normal vital
reduce. sign.
o Client know to 3. Maintain bed 3. To make
reduce pain. rest, provide comfortable
o Report quiet and reduce
comfort after environment. pain.
pain
decreased. 4. Teach client 4. To decrease
relaxation or reduce
technique and pain.
distraction and
using warm
compress.
5. Collaboration to 5. To decrease
give analgesic pain.
drugs.
6. Health 6. To increase
education about client
dyspepsia. knowledge
about his
disease.
2. Risk for lack After do nursing 1. Monitor the skin 1. Poor skin
of fluid action risk for turgor every shift turgor is a sign
volume related lack of fluid and record losses of
to not enough volume can and input fluid. dehydration.
fluid intake decrease in 1x4 2. Check the 2. Dry mucous
and excessive hours with mucous membranes
fluid loss due criteria: membrane of the which is a sign
to vomiting Client drink 8 mouth of each of
glassess shift. dehydration.
Client said 3. Monitor vital 3. Tachycardia,
that he not got signs every 4 hypotension,
diarrhea hours. dyspnea, or
Normal pulse fever may
indicate fluid
volume deficit.
46
4. Measure the 4. Measurement

patient's weight of body weight
every day and per day can
record the result. help estimate
the status of
body fluids.
5. Save oral fluid at 5. This action
a place easily allows patients
accessible at the to control the
bedside of the intake of extra
patient and fluids and
instruct the parenteral
patient to drink. fluid intake.
6. Collaboration in 6. To increase
giving infuse. fluid balance
and increase
fluid on client
body.
7. Health education 7. to make client
about important know how
of fluid. important of
fluid in his
body.
3. Imbalance Nutrition less than 1. Weigh the weight 1. To know client
Nutrition less body every day; development
than body requirements can monitor the result of body
requirement be solved in 7x24 of laboratory test. conduction.
related to less hours with Explain the
of appetite criteria: importance of
Client appetite adequate
become good nutritional intake
Client able to targets for each
finish food major meal and
that given for snack.
him. 2. Examine 2. Show the
Measure client nutritional status. factors that
body weight. affect
Client not felt nutritional
nausea and needs.
vomit. 3. Examine cause 3. To determine
Normal less of appetite. right
Hemoglobin. intervention.
4. Explain the 4. To increase
importance to client family
meeting the the importance
nutritional needs. for body and
healing
process.
5. Suggest client to 5. To increase
eat little but often client want to
47
and help client to eat.

rest before eating.
6. Suggest to client 6. To increase
family to bring client appetite.
client favorite
food.
7. Collaboration 7. To make client
with nutritionist increase of
in giving diet. appetite.
8. Collaboration in 8. To increase
giving drug with client nutrition
doctor. status.
9. Collaboration in 9. Increasing Hb
blood transfusion level into
with doctor. normal range.
4. Ineffective In 1x1 shift of 1. Assess breath 1. Ronkhi show
breathing ineffective airway function, sound, that
pattern related clearance can be irama, rapitidy, to accumulation
to pain solved with use muscle of secret and
criteria: breath. ineffective
o Good secret the
breathing secretion is cn
pattern. caused muscle
o Normal RR of breath and
o Regular increase of
o Client said breath.
that not felt 2. Set of semi 2. Maximally of
breathlessness fowler position. lung
o Not looked expansion,
use O2 decrease of
o Not using effort breath.
breathing aids. 3. Collaborate to 3. To decreas of
o Not using give medicine breathlessness.
chest appropriate
respiration. indication.
4. Assess vital sign. 4. To know the
general
5. Give O2 3 ltr. condition.
5. To help client
in breath.
48
3.11. Implementation
Table 3.7 Implementation
No Day/date Time Diagnose Implementation evaluation Sign
1. Monday, 08.30 I 1. Ask client to 1. Client said
june 1st tell his pain, that his
2015 causes, and level pain
characteristic is 3
of pain. (severe). Shadiq
P: abdominal
pain and can
increase the
pain when get
pressure.
Q: feels like
burn
R: left
abdomen
S: 3 (severe)
T: long pain
come is 3
minute and
can decrease
when not get
pressure
2. Obs vital sign. 2. BP :
110/70
mmHg
P : 104x/
minute
RR : 22x/
minute
Temp:
37C.
3. Maintain bed 3. he felt
rest in semi better
fowler when in
position, semi
provide quiet fowler
environment. position.
4. Teach client 4. Client do
relaxation relaxation
technique and technique
distraction and when he
using warm felt pain
compress. and the
family
compress
client when
he felt
49
pain.
5. Collaboration 5. After 10
to give minutes get
analgesic treatment
drugs. client said
antrain that his
injection pain was
with dose decreased
3x 2 mg.
As.
Traneksama
t 3x300 mg.
Ranitidine
2x25 mg.
6. Health 6. Client
education know
about about his
dyspepsia disease
include: after nurse
- definition, explaining
- etiology, about
- sign and definition,
symptom of etiology
dyspepsia. sign and
symptom
of
dyspepsia.
2. 09.00 II 1. Monitor the 1. Client skin
skin turgor turgor
every shift and looked dry.
record losses Input :
and input 2.725 shadiq
fluid. cc
Output
: 3.240
cc.
2. Check the 2. Client
mucous mouth
membrane of mucous
the mouth of looked dry.
each shift.
3. Monitor vital 3. BP: 110/70
signs every 4 mmHg
hours. P : 104x/ m
RR: 22x/
m
Temp:
37C.
4. Measure the 4. Client
patient's weight is
50
weight every 60 kg.

day and record
the result.
5. Save oral fluid 5. Oral fluid
at a place already
easily beside his
accessible at bedside
the bedside of and client
the patient and sometimes
instruct the drinking.
patient to
drink.
6. Collaboration 6. Client got
in giving rehydration
infuseNacl form
with 20 dpm. increasing
fluid.
7. Health 7. Client
education understand
about what nurse
important of explaining
fluid include: about :
sign and sign and
symptom of symptom
fluid loss of fluid
loss.
3. 09.30 III 1. Weigh the 1. Client
weight every body
day; monitor weight is
the result of 60 kg.
laboratory IBW : 63- shadiq
test. Explain 77 kg.
the
importance of
adequate
nutritional
intake targets
for each major
meal and
snack.
2. Examine 2. Client said
nutritional that he
status. cant eat
well.
3. Examine cause 3. Client said
less of that he felt
appetite. less of
appetite
cause of
pain in his
51
abdomen.
4. Explain the 4. Client
importance to understand
meeting the what nurse
nutritional explaining.
needs include:
- how
important keep
the nutritional
for client.
5. Suggest client 5. Client eat
to eat little but little but
often and help often after
client to rest nurse
before eating. orders.
6. Suggest to 6. Client
client family to usually eat
bring client his favorite
favorite food. menu.
7. Collaboration 7. Client has
with given that
nutritionist in diet for
giving diet keep client
include: nutritional
- entrasol status.
3x300 cc
8. Collaboration 8. Client
in giving drug appetite is
with doctor still low
include: after giving
- neurobion treatment.
2x10 mg with
route IV.
9. Collaboration 9. Hb : 2.7
in blood
transfusion
with doctor.
- blood
transfusion 2
kolf x 1 day.
4. 10.00 IV 1. Assess breath 5. There is no
function, sound such
sound, irama, as ronkhi
rapitidy, to RR: 22x/m
use muscle of shadiq
breath.
2. Set of semi 6. Client in
fowler semi
position. fowler
position
52
and he felt
better
when in
that
position.
3. Assess vital 7. BP: 110/70
sign. mmHg
P : 89x/ m
RR:22x/ m
Temp:37,1
C
4. Give O2 3 ltr 8. When get
with used oxygen
nasal canule. client
respiration
have
normal and
reguler.
3.12. Evaluation
Table 3.8 Evaluation
No Day/date Time Diagnose Evaluation
1. Tuesday, 08.30 I S:
june 2nd Client said that he still felt pain on his
2015 abdomen.
Client said that he felt dizziness.
O:
Client looked cant control pain.
Client looked still pain.
Client know how to reduce pain.
Client not report the pain was decrease
A: Problem is not solved yet
P: Continue intervention
1. Assess pain scale
2. Assess vital sign
5. Give analgesic drugs
2. 09.00 II O:
Client still drink 4 glassess.
Client still got diarrhea.
Client pulse is fast and irregular.
A: problem is not solved yet
P: continue intervention
2. Check the mucous membrane each
shift
3. Monitor vital sign.
4. Measure client weight every day.
53
3. 09.30 III S:
Client said that he still felt anorexia
Client said that he still felt vomit
O:
Client appetite still bad.
Client looked not finish the food that
given.
Client body weight still under normal.
Client still felt nausea and vomited.
1. Examine cause of appetite
3. Measures client body weight
5. Suggest to eat little but often
4. 10.00 IV S:
Client said that he felt breathlessness
O:
Client still felt breathlessness.
Client using chest respiration.
Client using breathing aids.
Client RR still irregular.
Client breathing pattern still abnormal.
1. Assess client respiration status
3.15. Progress note

Table 3.9 Progress note
No Day/date Time Diagnose Implementation Evaluation Sign
1. Wednesday, 09.30 I 1. ask client to tell S:
June 3rd 2015 his pain, causes, Client said that
and he still felt pain
characteristic of on his shadiq
pain. abdomen.
(Client said that Client said that
his level pain is he felt
3 (severe). dizziness.
P: abdominal O:
pain and can Client looked
increase the can control
pain when get pain.
pressure. Client looked
Q: feels like still pain.
burn Client know
R: left abdomen how to reduce
S: 3 (severe) pain.
T: long pain Client report
54
come is 3 the pain was

minute and can decrease
decrease when A:
not get Problem is not
pressure). solved yet
2. Obs vital sign. P:
(BP : 110/70 Continue
mmHg intervention
P : 104x/ minute 1. Assess pain
RR : 22x/ scale.
minute 2. Assess vital
Temp: 37C). sign.
5. Give analgesic
3. Maintain bed drugs.
rest in semi
fowler position,
provide quiet
environment.
(he felt better
when in semi
fowler position).
4. Teach client
relaxation
technique and
distraction and
using warm
compress.
(Client do
relaxation
technique when
he felt pain and
the family
compress client
when he felt
pain).
5. Collaboration to
give analgesic
drugs.
antrain
injection with
dose 3x 2
mg.
As.
Traneksamat
3x300 mg.
Ranitidine
2x25 mg.
(After 10
minutes get
treatment client
55
said that his pain

was decreased).
6. Health
education about
dyspepsia
include:
- definition,
- etiology,
- sign and
symptom of
dyspepsia.
(Client know
about his
disease after
nurse explaining
about definition,
etiology sign
and symptom of
dyspepsia).
2. 10.00 II 1. Monitor the skin O:

turgor every Client still drink
shift and record 4 glassess.
losses and input Client still got
fluid. diarrhea. shadiq
(Client skin Client pulse is
turgor looked fast and irregular.
dry. A:
Input: 2.725 problem is not
cc solved yet
Output: P:
3.240 cc). continue intervention
2. Check the 2. check
mucous mucous
membrane of membrane
the mouth of each shift.
each shift. 3. Monitor vital
(Client mouth sign.
mucous looked 4. Measure
dry). client weight
3. Monitor vital every day.
signs every 4
hours.
(BP: 110/70
mmHg
P : 104x/ m
RR: 22x/ m
Temp: 37C).
4. Measure the
patient's weight
56
every day and

record the
result.
(Client weight is
60 kg).
5. Save oral fluid
at a place easily
accessible at the
bedside of the
patient and
instruct the
patient to drink.
(Oral fluid
already beside
his bedside and
client
sometimes
drinking).
6. Collaboration in
giving
infuseNacl with
20 dpm.
(Client got
rehydration
form increasing
fluid).
8. Health
education about
important of
fluid include:
7. sign and
symptom of
fluid loss.
(Client
understand what
nurse explaining
about : sign and
symptom of
fluid loss).
3. 11.00 III 1. Weigh the S:
weight every Client said that
day; monitor the he still felt
result of anorexia
laboratory test. Client said that shadiq
Explain the he still felt
importance of vomit
adequate O:
nutritional Client still felt
intake targets appetite.
for each major Client looked
57
meal and snack. not finish the

(Client body food that given.
weight is 60 kg. Client body
IBW : 63-77 weight still
kg). under normal.
2. Examine Client still felt
nutritional nausea and
status. vomited.
(Client said that A:
he cant eat Problem is not
well). solved yet
3. Examine cause P:
less of appetite. continue intervention
(Client said that 1. Measures
he felt less of client body
appetite cause weight.
of pain in his 3. Examine
abdomen). cause of
4. Explain the appetite.
importance to 5. Suggest to
meeting the eat little but
nutritional often.
needs include:
- how
important keep
the nutritional
for client.
(Client
understand what
nurse explaining
about
importance of
nutrition for
body).
5. Suggest client to
eat little but
often and help
client to rest
before eating.
(Client eat little
but often after
nurse orders).
6. Suggest to client
family to bring
client favorite
food.
(Client usually
eat his favorite
menu).
7. Collaboration
58
with nutritionist
in giving diet
include:
- entrasol 3x300
cc.
- blood
transfusion 2
kolf x 1 day
(Client has
given that diet
for keep client
nutritional
status).
8. Collaboration in
giving drug with
doctor include:
- neurobion
2x10 mg with
route IV.
(Client appetite
is still low after
giving
treatment).
9. Collaboration in
blood
transfusion with
doctor.
( Hb : 2.7)
4. 12.00 IV 1. Assess breath S:
function, sound, Client said that
irama, rapitidy, he felt
to use muscle of breathlessness
breath. O: shadiq
(There is no Client still felt
sound such as breathlessness.
ronkhi RR: Client looked
22x/m). using chest
2. Set of semi respiration.
fowler position. Client looked
(Client in semi using breathing
fowler position aids.
and he felt Client RR still
better when in irregular.
that position). Client breathing
3. Assess vital pattern still
sign. abnormal.
(BP:110/70 A:
mmHg Problem is not
P : 89x/ m solved yet
RR:22x/ m P:
59
Temp:37,1C). continue intervention

4. Give O2 3 ltr. 1. Assess client
(Client used respiration
oxygen with status.
nasal canule 3
ltr).
Progress note on Thursday, 4th 2015

1. Thursday, 09.30 I 1. ask client to tell S:
june 4th 2015 his pain, causes, Client said that
and he not felt pain
characteristic of on his
pain. abdomen. shadiq
(Client said that Client said that
his level pain is he not felt
3 (severe). dizziness.
P: abdominal O:
pain and can Client looked
increase the can control
pain when get pain.
pressure. Client know
Q: feels like how to reduce
burn pain.
R: left abdomen Client report
S: 3 (severe) the pain was
T: long pain decrease
come is 3 A:
minute and can Problem is solved
decrease when yet
not get P:
pressure). Stop intervention
2. Obs vital sign. 1. Assess pain
(BP : 110/70 scale.
mmHg 2. Assess vital
P : 104x/ minute sign.
RR : 22x/ 5. Give analgesic
minute drugs.
Temp: 37C).
3. Maintain bed
rest in semi
fowler position,
provide quiet
environment.
(he felt better
60
when in semi
fowler position).
4. Teach client
relaxation
technique and
distraction and
using warm
compress.
(Client do
relaxation
technique when
he felt pain and
the family
compress client
when he felt
pain).
5. Collaboration to
give analgesic
drugs.
antrain
injection with
dose 3x 2
mg.
As.
Traneksamat
3x300 mg.
Ranitidine
2x25 mg.
(After 10
minutes get
treatment client
said that his pain
was decreased).
6. Health
education about
dyspepsia
include:
- definition,
- etiology,
- sign and
symptom of
dyspepsia.
(Client know
about his
disease after
nurse explaining
about definition,
etiology sign
and symptom of
dyspepsia).
61
2. 10.00 II 1. Monitor the skin O:

turgor every Client still drink
losses and input Client still got Shadiq
fluid. diarrhea.
dry. A:
cc solved yet
Output: P:
2. Check the 2. Check mucous
mucous membrane
membrane of each shift.
the mouth of 3. Monitor vital
each shift. sign.
(Client mouth 4. Measure client
mucous looked weight every
dry). day.
3. Monitor vital
signs every 4
hours.
(BP: 110/70
mmHg
P : 104x/ m
RR: 22x/ m
Temp: 37C).
4. Measure the
patient's weight
every day and
record the
result.
(Client weight is
60 kg).
5. Save oral fluid
at a place easily
accessible at the
bedside of the
patient and
instruct the
patient to drink.
(Oral fluid
already beside
his bedside and
client
sometimes
drinking).
6. Collaboration in
giving infuse
62
Nacl with 20
dpm.
(Client got
rehydration
form increasing
fluid).
7. Health
education about
important of
fluid
include:sign and
symptom of
fluid loss.
(Client
understand what
nurse explaining
about : sign and
symptom of
fluid loss).
result of anorexia
importance of vomit
adequate O:
kg). under normal.
status. vomited.
well). solved yet
3. Examine cause P:
abdomen). cause of
63

nutritional often.
needs include:
- how
important keep
the nutritional
for client.
(Client
understand what
nurse explaining
about
importance of
nutrition for
body).
eat little but
often and help
client to rest
before eating.
(Client eat little
but often after
nurse orders).
family to bring
client favorite
food.
(Client usually
eat his favorite
menu).
7. Collaboration
with nutritionist
in giving diet
include:
- entrasol 3x300
cc.
- blood
transfusion 2
kolf x 1 day.
(Client has
given that diet
for keep client
nutritional
status).
8. Collaboration in
giving drug with
doctor include:
- neurobion
2x10 mg with
route IV.
(Client appetite
64
is still low after

giving
treatment).
9. Collaboration in
blood
transfusion with
doctor.
- blood
transfusion 2
kolf x 1 day.
(Hb : 6.4)
breath. O: shadiq
22x/m). using chest
sign. abnormal.
(BP:110/70 A:
mmHg Problem is not
RR:22x/ m P:
oxygen with status.
nasal canule 3
ltr).
65
Progress note on Friday, june 5th 2015

2. Friday, june 10.00 II 1. Monitor the skin O:
5th 2015 turgor every Client still drink
dry. A:
cc solved yet
Output: P:
mucous membrane
each shift. sign.
dry). day.
3. Monitor vital
signs every 4
hours.
(BP: 110/70
mmHg
P : 104x/ m
RR: 22x/ m
Temp: 37C).
4. Measure the
patient's weight
every day and
record the
result.
(Client weight is
60 kg).
5. Save oral fluid
at a place easily
accessible at the
bedside of the
patient and
instruct the
patient to drink.
(Oral fluid
already beside
his bedside and
client
sometimes
66
drinking).
6. Collaboration in
giving infuse
Nacl with 20
dpm.
(Client got
rehydration
form increasing
fluid).
7. Health
education about
important of
fluid include:
sign and
symptom of
fluid loss.
(Client
understand what
nurse explaining
about : sign and
symptom of
fluid loss).
result of anorexia
importance of vomit
adequate O:
kg). under normal.
status. vomited.
well). solved yet
3. Examine cause P:
67
abdomen). cause of
nutritional often.
needs include:
- how
important keep
the nutritional
for client.
(Client
understand what
nurse explaining
about
importance of
nutrition for
body).
eat little but
often and help
client to rest
before eating.
(Client eat little
but often after
nurse orders).
family to bring
client favorite
food.
(Client usually
eat his favorite
menu).
7. Collaboration
with nutritionist
in giving diet
include:
- entrasol 3x300
cc.
(Client has
given that diet
for keep client
nutritional
status).
8. Collaboration in
giving drug with
doctor include:
- neurobion
2x10 mg with
route IV.
(Client appetite
68
is still low after

giving
treatment).
9. Collaboration in
blood
transfusion with
doctor.
- blood
transfusion 2
kolf x 1 day.
(Hb : 6.4)
breath. O: shadiq
22x/m). using chest
sign. abnormal.
(BP:110/70 A:
mmHg Problem is not
RR:22x/ m P:
oxygen with status.
nasal canule 3
ltr).
Progress note on Saturday, june 6th 2015

2. Saturday, 10.00 II 1. Monitor the skin O:
june 6th turgor every Client still drink
2015 shift and record 5 glassess.
losses and input Client still got shadiq
69
fluid. diarrhea.
dry. A:
cc solved yet
Output: P:
mucous membrane
each shift. sign.
dry). day.
3. Monitor vital
signs every 4
hours.
(BP: 110/70
mmHg
P : 104x/ m
RR: 22x/ m
Temp: 37C).
4. Measure the
patient's weight
every day and
record the
result.
(Client weight is
60 kg).
5. Save oral fluid
at a place easily
accessible at the
bedside of the
patient and
instruct the
patient to drink.
(Oral fluid
already beside
his bedside and
client
sometimes
drinking).
6. Collaboration in
giving infuse
Nacl with 20
dpm.
(Client got
rehydration
70
form increasing
fluid).
7. Health
education about
important of
fluid include:
sign and
symptom of
fluid loss.
(Client
understand what
nurse explaining
about : sign and
symptom of
fluid loss).
result of anorexia
importance of vomit
adequate O:
kg). under normal.
status. vomited.
well). solved yet
3. Examine cause P:
abdomen). cause of
nutritional often.
needs include:
- how
71
important keep
the nutritional
for client.
(Client
understand what
nurse explaining
about
importance of
nutrition for
body).
eat little but
often and help
client to rest
before eating.
(Client eat little
but often after
nurse orders).
family to bring
client favorite
food.
(Client usually
eat his favorite
menu).
7. Collaboration
with nutritionist
in giving diet
include:
- entrasol 3x300
cc.
- blood
transfusion 2
kolf x 1 day
(Client has
given that diet
for keep client
nutritional
status).
8. Collaboration in
giving drug with
doctor include:
- neurobion
2x10 mg with
route IV.
(Client appetite
is still low after
giving
treatment).
9. Collaboration in
72
blood
transfusion with
doctor.
- blood
transfusion 2
kolf x 1 day.
(Hb : 8.0)
breath. O: shadiq
22x/m). using chest
sign. abnormal.
(BP:110/70 A:
mmHg Problem is not
RR:22x/ m P:
oxygen with status.
nasal canule 3
ltr).
Progress note on Monday, june 8th 2015

2. Monday, 10.00 II 1. Monitor the skin O:
june 8th turgor every Client still drink
2015 shift and record 6 glassess.
dry. A:
73
cc solved yet
Output: P:
mucous membrane
each shift. sign.
dry). day.
3. Monitor vital
signs every 4
hours.
(BP: 110/70
mmHg
P : 104x/ m
RR: 22x/ m
Temp: 37C).
4. Measure the
patient's weight
every day and
record the
result.
(Client weight is
60 kg).
5. Save oral fluid
at a place easily
accessible at the
bedside of the
patient and
instruct the
patient to drink.
(Oral fluid
already beside
his bedside and
client
sometimes
drinking).
6. Collaboration in
giving infuse
Nacl with 20
dpm.
(Client got
rehydration
form increasing
fluid).
7. Health
education about
important of
74
fluid include:
sign and
symptom of
fluid loss.
(Client
understand what
nurse explaining
about : sign and
symptom of
fluid loss).
day; monitor the he not felt
result of anorexia
Explain the he not felt
importance of vomit
adequate O:
nutritional Client not felt
meal and snack. finish the food
(Client body that given.
kg). under normal.
2. Examine Client not felt
status. vomited.
he cant eat Problem is solved
well). yet
3. Examine cause P:
less of appetite. Stop intervention
abdomen). cause of
nutritional often.
needs include:
- how
important keep
the nutritional
for client.
(Client
understand what
75
nurse explaining
about
importance of
nutrition for
body).
eat little but
often and help
client to rest
before eating.
(Client eat little
but often after
nurse orders).
family to bring
client favorite
food.
(Client usually
eat his favorite
menu).
7. Collaboration
with nutritionist
in giving diet
include:
- entrasol 3x300
cc.
- blood
transfusion 2
kolf x 1 day
(Client has
given that diet
for keep client
nutritional
status).
8. Collaboration in
giving drug with
doctor include:
- neurobion
2x10 mg with
route IV.
(Client appetite
is still low after
giving
treatment).
9. Collaboration in
blood
transfusion with
doctor.
- blood
transfusion 2
76
kolf x 1 day.
(Hb : 8.0)
to use muscle of breathlessness shadiq
breath. O:
22x/m). using chest
sign. abnormal.
(BP:110/70 A:
mmHg Problem is not
RR:22x/ m P:
oxygen with status.
nasal canule 3
ltr).
Progress note on Tuesday, june 9th 2015

2. Tuesday, 10.00 II 1. Monitor the skin O:
june 9th turgor every Client drunk 7
2015 shift and record glassess.
dry. A:
cc solved yet
Output: P:
mucous membrane
77

each shift. sign.
dry). day.
3. Monitor vital
signs every 4
hours.
(BP: 110/70
mmHg
P : 104x/ m
RR: 22x/ m
Temp: 37C).
4. Measure the
patient's weight
every day and
record the
result.
(Client weight is
60 kg).
5. Save oral fluid
at a place easily
accessible at the
bedside of the
patient and
instruct the
patient to drink.
(Oral fluid
already beside
his bedside and
client
sometimes
drinking).
6. Collaboration in
giving infuse
Nacl with 20
dpm.
(Client got
rehydration
form increasing
fluid).
7. Health
education about
important of
fluid include:
sign and
symptom of
fluid loss.
(Client
78
understand what
nurse explaining
about : sign and
symptom of
fluid loss).
4. 10.30 IV 1. Assess breath S: shadiq
irama, rapitidy, he not felt
breath. O:
(There is no Client not felt
ronkhi RR: Client not looked
22x/m). using chest
fowler position. Client not looked
and he felt Client RR has
better when in reguler.
3. Assess vital pattern normal.
sign. A:
(BP:110/70 Problem is solved
mmHg yet
P : 89x/ m P:
RR:22x/ m Stop intervention
Temp:37,1C). 1. Assess client
4. Give O2 3 ltr. respiration
(Client used status.
oxygen with
nasal canule 3
ltr).
Progress note on Tuesday, june 10th 2015

2. Tuesday, 10.00 II 1. Monitor the skin O:
june 10th turgor every Client drunk 8
2015 shift and record glassess.
losses and input Client not got
(Client skin Client pulse
turgor looked regular.
dry. A:
Input: 2.725 problem is solved yet
cc P:
Output: Stop intervention
79
3.240 cc). 2. Check mucous

2. Check the membrane
mucous each shift.
membrane of 3. Monitor vital
the mouth of sign.
each shift. 4. Measure client
(Client mouth weight every
mucous looked day.
dry).
3. Monitor vital
signs every 4
hours.
(BP: 110/70
mmHg
P : 104x/ m
RR: 22x/ m
Temp: 37C).
4. Measure the
patient's weight
every day and
record the
result.
(Client weight is
60 kg).
5. Save oral fluid
at a place easily
accessible at the
bedside of the
patient and
instruct the
patient to drink.
(Oral fluid
already beside
his bedside and
client
sometimes
drinking).
6. Collaboration in
giving infuse
Nacl with 20
dpm.
(Client got
rehydration
form increasing
fluid).
7. Health
education about
important of
fluid include:
sign and
80
symptom of
fluid loss.
(Client
understand what
nurse explaining
about : sign and
symptom of
fluid loss).
CHAPTER 4
CONCLUSION AND SUGGESTION
4.1. Conclusion
In the assessment on Monday, June 1st 2015, client said that he felt
abdominal pain in the right middle and left upper and the times
intermittent. Client said that his pain was unbearable and he felt heat and
felt like burn.
Nursing diagnose that found in client are, acute pain related to Agent
physical injury secondary to disease process (dyspepsia), risk for lack of
fluid volume related to not enough fluid intake and excessive fluid loss
due to vomiting, imbalance nutrition less than body requirement related
to less of appetite, and the last ineffective breathing pattern related to
pain.
Nursing care plan that determined are asking client to tell his pain and the
physical symptom that can cause pain, observing vital sign, setting client
position, teaching client relaxation technique and distraction and using
warm compress, collaborating to give analgesic drugs, and health
education about client disease.
The implementation was regulated based on nursing care plan that

already determined. The evaluation result that found during 10 days
intervention is acute pain related to Agent physical injury secondary to
disease process (dyspepsia), risk for lack of fluid volume related to not
enough fluid intake and excessive fluid loss due to vomiting, imbalance
nutrition less than body requirement related to less of appetite, and the
last diagnosis is ineffective breathing pattern related to pain are has
solved.
81
82
Documentation that done during nursing care process are using table by
formulating all of data which support subjectively or objectively.
4.2. Suggestion
4.2.1. For client and his family with dyspepsia, it is expected to checkup
or control for prevent disease relapsing of dyspepsia disease and
the other further complaints suggested to check the condition to
the health care providers. Client and his family need to build good
relationship with nurses and other health care worker in which to
make it perform in nursing care process to the client with
dyspepsia and expect client and family could participate more in
nursing care.
4.2.2. For the nurse, it is suggested to improve the knowledge especially

in the disease problem and its professionalism of giving nursing
care by implementing the nursing care based on standard that
already determined, careful on implementing nursing carefast
response on client complain and response, and able to
documented every nursing care rightly, so that the nursing care
that implemented is accountable. The nurse able to improve
relationship and collaborate with other health care providers.
4.2.3. For the management officer in the hospital, it is hope to give

standard nursing care especially on client with dyspepsia disease
so that the nurse able to use the standard of those nursing care to
improve service quality. The hospital officer is also hoped to prior
the best service for client. Without looking after the social status,
religion, tribe, nationality, or economy status based on clients
right, and make client and family easy on every affair related to
the care of patients, such as fast and responsible pharmacy
83
service, administration procedure, accurate laboratories

examination and supporting examination, careful and friendly.
4.2.4. For educational institution, they should always put effort to

improve knowledge and skill of student optimally, held the
coaching program in the skill of nursing care, scientific seminar,
and clear determination of nursing clinical practice target in every
nursing clinical practice that runs.
4.2.5. For the students, they should improve the skill and deepen the
nurse knowledge by reading and fulfilling the book collection
about nursing and improve quality skill that already learned by
educational institution.
REFERENCES
Annisa. Hubungan Ketidakteraturan Makan dengan Sindroma Dispepsia. 2009

Downloaded on 6th april 2015 from:
http://repository.usu.ac.id/bitstream/123456789/14275/1/10E00003.pdf
Applegate, Edith J. The Anatomy and Physiology Learning System. 4th edition
printed in United States of America, 2011.
Herman, B. (2004). Fisiologi Pencernaan untuk Kedokteran.Padang :Andalas

University Press.
Harahap, Y. (2009). Karakteristik Penderita Dispepsia Rawat Inap di Rumah

Sakit Martha Friska Medan year 2007. Downloaded on april 6 th 2015
from:
http://repository.usu.ac.id/bitstream/123456789/14681/1/10E00274.pdf
Herdman, T. Heather. Diagnosis Keperawatan : Definisi dan Klasifikasi 2012-

2014 / editor, T. Heather Herdman ; alih bahasa, Made Sumarwati, dan
Nike Budhi Subekti ; editor edisi bahasa Indonesia, barrarah Bariid,
Monica Ester, dan Wuriraptiani Jakarta: EGC, 2012.
J Majority, The Relation of Diet Pattern to Dyspepsia Syndrom in College

Students. 2015 downloaded on april 6th 2015.
Kumar A, Patel J, Sawant P. Epidemiology of Functional Dyspepsia. J Assoc Phys

India 2012;60:9-12.
Mahadeva et al. on Dispepsia.Murdani Abdullah, Jeffri Gunawan Divisi

Gastroenterologi, Bagian Ilmu Penyakit Dalam Fakultas Kedokteran
Universitas Indonesia, Jakarta, Indonesia 2012.
Murdani Abdullah, Jeffri Gunawan. Dispepsia, Divisi Gastroenterologi, Bagian

Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia,
Jakarta, Indonesia 2012.
84
Muttaqin, arif. Pengkajian Keperawatan Aplikasi Pada Praktik Klinik. Jakarta:
Salemba Medika, 2012.
Herdman, T. Heather. Diagnosa Keperawatan : definisi dan klasifikasi 2012-

2014/ editor, T. Heather Herdman alih bahasa, Made Sumarwati, dan
Nike Budhi Subekti: editor edisi bahasa indonesia. Barrarah Bariid,
Monica Ester, dan Wuri Praptiani Jakarta EGC. 2012
Rosita Ratna, 2011, Profil Kesehatan Indonesia Tahun 2011, Kementrian

Kesehatan Republik Indonesia 2012.
Susanti, A. (2011). Faktor risiko dyspepsia pada mahasiswa Institut Pertanian

Bogor (IPB). Downloaded on april 6th 2015 from:
http://fema.ipb.ac.id/index.php/faktor-risiko-dispepsia-pada-mahasiswa-
institut-pertanian-bogor-ipb-2.
Sabirin. M. et all. 2014. Students hand book nursing clinical practice II medical
surgical nursing. Editor Khailani Ahmad.
85
APPENDIXES
Appendix 1
Glasgow Coma Scale
Parameter Criteria Score

Open eyes spontaneously 4
EYES Opens eyes in response to voice 3
RESPONSE Open eyes response to painful stimuli 2
Doent open eyes 1
Oriented, converses, normally 5
Confused, disoriented 4
VERBAL Utter inappropriate 3
RESPONSE Incomprehensible sounds 2
Makes no sound 1
Obey the command 6
Extension to painful stimuli 5
MOTORIC Abnormal flexion to painful stimuli 4
RESPONSE Withdraw to painful stimuli 3
Localized painful stimuli 2
Makes no movement 1
Source : Priharjo, R. (2006). Pengkajian Fisik Keperawatan. Jakarta : EGC

Appendix 2
The Average Value of Blood Pressure
Age The Average Value (mmHg)

< 1 year old 63 (Flush Technique)
2 years old 93/30 mmHg
Teenager 120/75 mmHg
adult 120/80 mmHg

Appendix 3
Normal Pulse Rate
Cathegory Average Beats per Minute

The Unborn Child 140 to 150
Newborn 130 to 140
During First year 110 to 130
During Second year 96 to 115
During Third year 86 to 105
7 to 14 years old 76 to 90
After 60 years old 67 to 80
Note :
1. Pulse rate rise normally during excitement, following physical exertion and during
digestion.
2. Pulse rate is generally more rapid in female.
3. Pulse rate is also influenced by the breathing rate.

Appendix 4
Muscle Strength Scale
Scale Strength (%) Characteristic

1 0 Totally paralyze
2 10 No movement, there is muscle constriction
3 25 Full muscle movement, oppose gravity with
supporting
4 50 Normal movement, oppose gravity
5 100 Full normal movement, oppose the gravity with
little bit restrain
Source :Priharjo, R. (2006). Pengkajian Fisik Keperawatan. Jakarta : EGC

Appendix 5
Activity Scale
Activity scale Criteria

0 Can do self care
1 Need equipment
2 Need helping or supervising from other
3 Need helping or supervising from other and equipment
4 Really need helping , supervising ,from other people, cant do or
participating in self care/nursing care

Appendix 6
Pain Scale
Scale Pain response

0 No pain
1 Mild pain
2 Moderate pain
3 Severe pain
4 The most severe pain

Appendix 7
Human Body Temperature
Parameter Score
Oral 33.2 O 38.2O C (92 O 101O F)
Rectal 34.4 O 37.8O C (94 O 100O F)
Tympanic 35.4 O 37.8 O C (96 O 100 O F)
Axillaries 36.5 O 37.5O C (96 O 99 O F)

Appendix 8
The Average Value of Visus
The Average Value of Visus Detail

Visus 0 Nothing to see the light
Visus 1/- Can see the light with range 1 meter
Visus 1/300 Can see hand movement with range 1 meter
Visus 5/60 Can see or count the fingers with range 1 meter

Appendix 9
Signs of infection on eye
Sign Description
Red eyes Red eyes are caused by the enlarged and
dilated blood vessels in the surface of the
eye (conjunctiva) becoming irritated.
Persistent Itching Allergic reactions occur when the surface
of your eye is exposed to allergens. The
reaction triggers the release of histamines
which causes itchy eyes, as well as other
symptoms like red and watery eyes.
Rubbing your itchy eyes is highly
discouraged. As you rub your eyes, you
release more and more histamines which
results in worse symptoms.
Flaking of the eye lids Is fall of eyelids
Discomfort Feeling does not comfort with the eye
Blurred vision There could be an underlying problem if
youre experiencing blurry vision. Blurred
vision is usually the red flag that something
else exists. People who forget to wear their
prescribed corrective lenses experience
blurry vision.
Watery eyes Epiphora happens one of two ways: either
the tear drainage duct is not functioning
properly or the eye is producing more tears
than necessary. The production and
drainage of tears is a function of the
lacrimal drainage system.
Eye discharge Eye discharge is a yellowish, sticky, crusty
substance that can sometimes make your
eyes feel glued shut. It can be temporary
such as when you wake up in the morning,
or persistent in which medical attention
should be considered.
Eye pain Eye pain can be a very uncomfortable
feeling and sometimes is referred to as a
stabbing, throbbing, burning, gritty, sharp,
aching or something in my eye feeling.
Swollen eyelids discomfort, embarrassment, impaired
vision and difficulties when applying
cleanser or make-up, touching or rubbing,
eyelid swelling can become serious if its
not treated properly and quickly.
Swelling Around Eye It look like swelling on eye surface.
Source :http://surgery.about.com/od/aftersurgery/qt/SignsInfections.htm
Appendix 10
Anxiety level
Pain level Pain scale Description

Mild anxiety 1 Problem and anxious in
daily that make client
increase his focus in a
problem
Signs and symptoms :
Increase blood pressure,
shortness of breath,
palpitation, mild tremor,
increase voice volume.
Moderate anxiety 2 Focus on problem and ignore
with the other thing
Sign and symptoms :
Increase blood pressure,
difficult to sleep, increase
voice volume, increase
respiration, easy to get upset,
diarrhea, and constipation
Severe anxiety 3 Focus in very specific
problem, deny the other
perspective
Shortness of breath,
palpitation, felt pain in chest,
increase blood pressure,
sweating, couldnt logic in
thinking
Panic 4 Become aggressive and
uncontrolled , fear about
something that treated life
Shout up something, panic,
could not response with an
order, pupil distortion,
increase dramatically in
respiration and pulse,
incoherent, hypotension, pale
and suspect to treat himself
or other

Appendix 11
CURICULUM VITAE
Name : Muhammad Shadiq Aulia Rahman
Sex : Male
Dat of Birth : August, 4th 1994
Nationality : Indonesia
Religion : Moeslim
Fathers Name : Suratman, S.Kep., MM
Mothers Name : Siti Muinah
Marital Status : Single
Address : Desa. Suryatama RT.05 Kec.Halong Kabupaten Balangan
Formal Education
2000 2002 : SDN MIHU 2
2002 2003 : SDN BALIKPAPAN UTARA
2004 2006 : SDN MIHU 2
2007 - 2009 : SMP DARUL HIJRAH PUTRA
2010 2012 : MADRASAH ALIYAH DARUL HIJRAH PUTRA
2013 2015 : Banjarmasin Muhammadiyah Health College International

Class of Nursing Diploma Program

Kti M Shadiq Aulia Rahman

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Kti M Shadiq Aulia Rahman

Încărcat de

Drepturi de autor:

Formate disponibile

NURSING CARE REPORT ON MR.

MEDICAL DIAGNOSIS IN TULIP IIIC WARD

BANJARMASIN ULIN GENERAL HOSPITAL

MUHAMMAD SHADIQ AULIA RAHMAN

SRN : 12144011156 D3KI

BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE

INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM

MEDICAL DIAGNOSIS IN TULIP IIIC WARD AT

BANJARMASIN ULIN GENERAL HOSPITAL

Proposed to Fulfill One of the Requirements to Accomplish

International Class of Nursing Diploma Program

MUHAMMAD SHADIQ AULIA RAHMAN

SRN : 1214 4011 156

BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE

INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM

ACADEMIC YEARS 2014/2015

1. Thanks to Allah SWT.

Banjarmasin, July, 2015

CHAPTER 1 INTRODUCTION .............................................................. 1

CHAPTER 2 THEORETICAL REVIEW ................................................ 6

CHAPTER 3 NURSING CARE .............................................................. 29

CHAPTER 4 CLOSSING ........................................................................ 81

Table Page number

Majority (2015) on his book said that dyspepsia is a collection of

rate, is 5% of all visits to primary health care facilities. In fact, a study in

In Indonesia, an estimated nearly 30% of patients who come to the

Based on data obtained gastroenterologist clinic visits in approximately

According to the (Department, 2011), the number of patients hospitalized

Based on the survey results at theBanjarmasin Ulin General Hospital,

1.2. Problem Formulation

1.3. Special Purpose

1.4. Benefits of Writing

1.5. Method of Nursing Care

1.6. Systematics of Writing

Chapter 2 theoretical background, include anatomy and physiology,

Chapter 3 the results of nursing care, consisting of illustration the case,

Chapter 4 Conclusions and suggestions.

2.1. Medical of Theoritical Review

Figure 1 features of the stomach

longitudinal muscle fibers. The oblique layers adds another

2.2. Nursing Theoritical Review

In the same lime with susanti, Kumar A, Patel J, Sawant

In the same lime with susanti, Abdullah, Gunawan (2012:647) on

Furthermore, Majority (2015:73) on his book stated that

From the definition above, the writer concludes that dyspepsia is

satiety, heartburn, bloating, belching, anorexia, nausea, and

Common causes of dyspepsia include:

2.2.2.5. Gallbladder pain (biliary colic) or inflammation

the production of acidExcessive gastric mucosal wall

2.2.3.4. Disorders of gastric accommodation.

Incidence of H. pylori infection are around 50% in

Decreased food intake

Increased HCL production

Erode stomach wall

Afferent nerv Stimulated stomach nerv Irritation stomach wall

Medulla spinalis hypothalamus Uncomfortable feeling in

Cerebral cortex HCL irritate stomach wall

2.2.4. Sign and symptom

Most people will experience some symptoms of dyspepsia within

2.2.5. Diagnostic examination

2.2.6. Medical treatment

2.2.6.2. Pharmacologic management namely:

2.2.7. Non Medical Treatment

2.2.7.8. Do not wear tight clothing around your middle.